后腹腔镜联合膀胱电切镜对上尿路移行细胞癌根治性治疗的安全性研究

目的探讨后腹腔镜联合膀胱电切镜对肾盂、中上段输尿管移行细胞癌根治性治疗的手术及肿瘤学安全性。方法回顾性分析肾盂、中上段输尿管移行细胞癌患者58例临床资料,后腹腔镜联合膀胱电切镜肾输尿管全长切除组（A组）41例,开放肾输尿管切除组（B组）17例。对其手术效果、并发症及术后肿瘤复发情况进行对比。结果A组和B组手术出血量（98．4和165mL）、术后住院天数（7．1和8．0d）、术后应用止痛药时间（1．2和3．1d）比较,A组优于B组（P〈0．05）;两组手术时间（150和110min）、术后留置尿管时间（6．2和3．5d）比较,A组长于B组（P〈0．05）。A组1例因电切输尿管口出血,中转开放手术。A、B两组并发症发生率（7．3％和11．8％）及肿瘤复发率（14．6％,23．5％）差异均无统计学意义（P均〉O．05）。结论联合尿道电切镜、后腹腔镜肾输尿管切除术与开放手术相比,出血少、术后恢复快、并发症少,未增加术后肿瘤的复发。     

后腹腔镜联合尿道电切镜根治性肾输尿管切除治疗上尿路移行细胞癌(附16例报告)

目的 探讨后腹腔镜联合尿道电切镜根治性肾输尿管切除治疗上尿路移行细胞癌的方法和临床疗效. 方法 对10例肾盂癌、6例输尿管上中段移行细胞癌先采用尿道电切镜行患侧输尿管口膀胱黏膜袖套状切除,而后行后腹腔镜根治性肾输尿管全切术. 结果 16例手术均获成功,平均手术时间120 min,术中出血平均80 ml,患者均于术后36～48 h下床活动,术后住院时间8～14 d(平均9.4 d),术后随访膀胱局部复发2例. 结论 后腹腔镜联合尿道电切镜根治性肾输尿管切除治疗上尿路肿瘤是一种安全、有效的微创手术方法,实用性较强,具有良好的应用前景.     

根治性切除治疗上尿路移行上皮癌

采用经腹行肾筋膜外肾、输尿管全长及膀胱壁袖状切除加腹膜后清扫的根治性切除术治疗上尿路移行细胞癌２５例，术后５～１２年存活２２例；术后３年内死亡３例，其中１例与原发病无关，另２例为继发膀胱癌或对侧肾盂癌，但无腹膜后局部复发的临床证据。认为本术的切除范围有利于预防肿瘤的局部复发。     

上尿路移行细胞癌腔镜下治疗进展

上尿路移行细胞瘤腔镜下的治疗近年来发生了根本的变化，出现了腔镜下保存上尿路的细胞瘤切除术，本文对该方法近年来有关进展进行了综述。     

上尿路移行细胞癌两种开放手术疗效比较

39例上尿路移行细胞癌患者术后五年生存率为53.8％,其中根治性手术组52.4％。保守性手术组55.6％,两组比较P>0.05。根据分期分级两个变量进行不同分层间比较,两种手术方式在高期(C期)术后五年生存率有统计学意义。术后五年为尿路移行细胞癌复发率两种术式无明显差异。移行细胞癌复发于膀胱者占80％。发生输尿管残端移行细胞癌4例。     

上尿路移行细胞癌(附71例报告)

目的探讨上尿路移行细胞癌的诊断方法和治疗效果。方法回顾性分析近１０年来收治的７１例经病理证实的上尿路移行细胞癌。术前行尿脱落细胞学检查６０例,ＣＴ检查６１例;行肾输尿管及膀胱袖状切除６４例,术后随访６８例。结果尿细胞学和ＣＴ的阳性率分别为７２％和９３％。２６例术后再发膀胱癌。结论尿脱落细胞学检查是较好的定性诊断方法,ＣＴ检查是重要的定位诊断方法。肾输尿管及膀胱袖状切除术仍是主要的治疗方法。病人的预后与肿瘤部位、临床分期、病理分级及ＤＮＡ的倍体类型有关。     

腹腔镜联合尿道电切镜行肾输尿管切除并膀胱袖状切除术治疗上尿路肿瘤

目的:总结腹膜后腹腔镜联合尿道电切镜行肾输尿管切除并膀胱袖状切除术治疗上尿路移行细胞癌的临床经验.方法:回顾分析9例肾盂癌、8例输尿管癌患者的临床资料.术中先用电切镜经尿道袖状分离输尿管管口及壁内段,再切除肾、输尿管,并记录相关指标,术后常规用丝裂霉素或吡柔比星灌注膀胱.结果:16例手术顺利完成,1例因右肾切除时损伤下...     

输尿管镜活检在上尿路移行细胞癌诊断中的准确性(附35例报告)

目的探讨上尿路移行细胞癌诊断中输尿管镜活检结果与术后病理结果之间的关系，以指导进一步治疗。方法35例患者均进行输尿管镜检查及肿物活检，行手术完整切除并行病理检查。活检标本和术后大体病理标本按WHO进行病理分级和分期。结果在22例Ⅱ级和Ⅱ级以下的输尿管镜活检病例中有2例Ⅲ级或Ⅲ级以上高分级的病例，在9例Ⅱ级以上的输尿管镜活检病例中有7例Ⅲ级或Ⅲ级以上高分级的病例。在22例Ⅱ级和Ⅱ级以下的输尿管镜活检病例中有1例出现pT2和pT3分期。而在9例Ⅱ级以上的输尿管镜活检病例中有6例术后侵犯肌肉或肾实质的pT2和pT3分期。结论输尿管镜取得上尿路移行细胞癌的标本可以获得准确的分级，并且这个分级与术后大体病理的分级和分期具有较好的相关性。     

后腹腔镜联合经尿道输尿管口电切治疗上尿路尿路上皮癌

目的探讨后腹腔镜联合经尿道输尿管口电切行上尿路尿路上皮癌（upper urinary tract urothelial carcinoma,UUT—UC）根治性切除术的疗效。方法2009年4月～2012年1月,对21例UUT—UC采用后腹腔镜联合经尿道输尿管口电切行肾、输尿管、膀胱袖状切除术。先经尿道行输尿管口电切使输尿管与膀胱完全脱离,后腹腔镜下行肾及上段输尿管的游离和切除,取标本同时游离中下段输尿管以完成全程输尿管的切除。结果21例手术均成功,手术时间80～150min,平均110min,术中出血量60～180ml,平均100ml;无严重并发症发生。术后住院8～14d,平均9．5d。病理检查均为UUT—UC,其中肾盂癌15例,输尿管癌6例,20例T1-2N0M0,1例T3N0M0。21例随访4～36个月,平均20个月,均未见肿瘤复发及转移。结论后腹腔镜手术联合经尿道输尿管口电切治疗低级别肾盂癌和上段输尿管癌安全、有效。     

腹腔镜治疗上尿路移行细胞癌合并膀胱前列腺疾病

目的探讨腹腔镜治疗上尿路移行细胞癌合并膀胱前列腺疾病的临床效果。方法腹腔镜行肾输尿管全长、膀胱袖状切除和膀胱疾病处理及前列腺摘除术共10例。结果10例手术全部成功,术后无并发症,效果良好。随访3个月~3年未见局部复发和远处转移。结论该法不仅具有腹腔镜创伤小、恢复快的优点,且处理合并症简单,适合治疗上尿路移行细胞癌合并膀胱前列腺疾病。     

后腹腔镜双侧一期肾输尿管全长切除术——肾移植术后原上尿路移行细胞癌8例报告

目的探讨肾移植术后发现原肾肾盂癌和(或)输尿管癌一期行后腹腔镜双侧肾输尿管全长切除术的安全性与可行性。方法 2006年4月~2009年11月对8例肾移植术后发现原肾肾盂癌和(或)输尿管癌行腹腔镜下双侧一期肾输尿管全长切除。先取左侧卧位,后腹腔镜下游离右侧肾及输尿管,输尿管远端用钛夹夹闭;改为右侧卧位后同法处理左侧肾及输尿管;然后取截石位,经尿道用电切镜袖状切除双侧输尿管膀胱膀胱壁内段;最后取下腹正中6 cm切口取出标本。结果 8例均行后腹腔镜双侧肾输尿管全长切除联合经尿道膀胱袖状切除,其中1例因膀胱内发现肿物同时行经尿道膀胱电切术,无中转开腹。手术时间(346.9±105.4)min(230~574 min);术中出血量(162.5±102.6)ml(100~400 ml),均无输血;住院时间(18.3±5.7)d(12~49 d)。病理报告均为尿路上皮癌,其中2例为双侧病变,此2例中有1例合并膀胱癌。8例随访(22.6±14.2)月(6~49个月),其中1年6例,均存活,1例膀胱癌复发相继行电切、膀胱部分切除治疗。结论肾移植术后原肾肾盂癌或输尿管癌一期行后腹腔镜双侧肾输尿管全长切除术是一种安全可行的治疗方式。     

完全腹腔镜肾盂输尿管癌根治术治疗上尿路肿瘤32例报告

目的探讨完全腹腔镜肾盂输尿管癌根治术治疗上尿路肿瘤的疗效。方法 2007年11月～2011年3月行完全腹腔镜肾盂输尿管癌根治术32例。70°～90°健侧卧位,建立人工气腹,于脐缘、平脐腋前线、锁骨中线肋缘下和脐与耻骨联合连线中点置入trocar,先在肾周筋膜外切除肾脏后,向下游离输尿管至膀胱壁段,膀胱充水后打开膀胱,吸净液体,观察双侧输尿管开口,袖状切除患侧输尿管,3-0可吸收线连续缝合膀胱切口,2-0可吸收线间断加固肌肉层,腰部取5～7 cm切口取出标本。结果 32例手术均获成功,无中转开放手术。手术时间80～150 min,平均100 min。术中出血量80～200 ml,平均150 ml。引流量50～150 ml/d,平均100 ml/d,术后24～48 h拔除引流管。术中、术后无明显手术并发症。住院时间7～14 d,平均9 d。32例病理诊断均为尿路上皮癌。32例随访4～40个月,平均23.2月,1例术后1年死于肺转移,其余均无瘤生存。结论完全腹腔镜肾盂输尿管癌根治术具有创伤小、术后恢复快的优点,是一种安全、有效的治疗方法。     

Oncologic Outcomes Following Three Different Approaches to the Distal Ureter and Bladder Cuff in Nephroureterectomy for Primary Upper Urinary Tract Urothelial Carcinoma

Background

There is a lack of consensus regarding the prognostic significance of different approaches to the bladder cuff at surgery for primary upper urinary tract urothelial carcinoma (UUT-UC).

Objectives

To compare the oncologic outcomes following radical nephroureterectomy using three different methods of managing the bladder cuff.

Design, setting, and participants

From January 1990 to December 2007, 414 patients with primary UUT-UC underwent radical nephroureterectomy at our institution. Of these, 301 were included in our study.

Intervention

Three methods of bladder cuff excision—intravesical incision, extravesical incision, and transurethral incision (TUI)—were performed.

Measurements

Patients’ medical records were reviewed retrospectively. The clinicopathologic data and oncologic outcomes were compared among groups.

Results and limitations

Of the 301 patients, 81 (26.9%) underwent the intravesical method, 129 (42.9%) underwent the extravesical technique, and 91 (30.2%) underwent TUI. There were no differences in clinical and histopathologic data among the three groups. When comparing the intravesical, extravesical, and TUI techniques, bladder recurrence developed in, respectively, 23.5%, 24.0%, and 17.6% cases (p = 0.485); local retroperitoneal recurrence in 7.4%, 7.8%, and 5.5% (p = 0.798); contralateral recurrence in 4.9%, 3.9%, and 2.2% (p = 0.632); and distant metastasis in 7.4%, 10.4%, and 5.5% (p = 0.564). There were no differences in recurrence-free and cancer-specific survival among the three groups (p = 0.680 and 0.502, respectively).

Conclusions

The three techniques had comparable oncologic outcomes. Our data validate the TUI method of bladder cuff control in patients with primary UUT-UC without coexistent bladder tumors.     

Laser Therapy for Upper Urinary Tract Transitional Cell Carcinoma: Indications and Management

Context

Ureteroscopically guided laser techniques are commonly used in the treatment of upper urinary tract transitional cell carcinoma (UUTT); however, there is an ongoing debate with regard to indication and management.

Objective

To review the indication, feasibility, and treatment outcome of laser application for definitive endoscopic treatment of UUTT, focusing on technical aspects of different laser devices and their impact on tissue.

Evidence acquisition

PubMed and Medline were searched for reports on laser therapy in UUTT from 1980 to 2008, with particular focus on the technical background of various laser systems.

Evidence synthesis

For decades, nephroureterectomy has been considered the gold standard for treating UUTT. With the intent to preserve functioning renal parenchyma, minimally invasive approaches, initially advocated for patients requiring a nephron-sparing approach (ie, single functioning kidney, renal insufficiency or significant comorbidities), have gained widespread acceptance due to advances in ureteroscopy, percutaneous renal surgery, and laparoscopy. Ureteroscopically guided laser ablation has been used successfully, resulting in recurrence rates ranging from 31% to 65% and disease-free rates of 35% to 86%, depending on stage and grade at diagnosis.

Conclusions

To obtain the highest treatment success, the initial staging and grading of the tumour is crucial. Because low-grade tumours rarely if ever progress in stage or grade, the success rate of ureteroscopic therapy parallels that of endoscopic resection of identical bladder tumours. In the treatment of higher grade, advanced tumours, ureteroscopic therapy is less likely to be curative, and thus, endoscopic manoeuvres can only be palliative. Due to the relatively low prevalence of this tumour and the lack of comparable randomised, multicentre trials, the indications for an endoscopic laser treatment option has to be defined based on the patient's individual situation.     

Impact of Tumor Location on Prognosis for Patients with Upper Tract Urothelial Carcinoma Managed by Radical Nephroureterectomy

Background

There is a lack of consensus regarding the prognostic significance of ureteral versus renal pelvic upper tract urothelial carcinoma (UTUC).

Objective

To investigate the association of tumor location on outcomes for UTUC in an international cohort of patients managed by radical nephroureterectomy (RNU).

Design, setting, and participants

A retrospective review of institutional databases from 10 institutions worldwide identified patients with UTUC.

Intervention

The 1249 patients in the study underwent RNU with ipsilateral bladder cuff resection between 1987 and 2007.

Measurements

Data accrued included age, gender, race, surgical approach (open vs laparoscopic), tumor pathology (stage, grade, lymph node status), tumor location, use of perioperative chemotherapy, prior endoscopic therapy, urothelial carcinoma recurrence, and mortality from urothelial carcinoma. Tumor location was divided into two groups (renal pelvis and ureter) based on the location of the dominant tumor.

Results and limitations

The 5-yr recurrence-free and cancer-specific survival estimates for this cohort were 75% and 78%, respectively. On multivariate analysis, only pathologic tumor (pT) classification (p < 0.001), grade (p < 0.02), and lymph node status (p < 0.001) were associated with disease recurrence and cancer-specific survival. When adjusting for these variables, there was no difference in the probability of disease recurrence (hazard ratio [HR]: 1.22; p = 0.133) or cancer death (HR: 1.23; p = 0.25) between ureteral and renal pelvic tumors. Adding tumor location to a base prognostic model for disease recurrence and cancer death that included pT stage, tumor grade, and lymph node status only improved the predictive accuracy of this model by 0.1%. This study is limited by biases associated with its retrospective design.

Conclusions

There is no difference in outcomes between patients with renal pelvic tumors and with ureteral tumors following nephroureterectomy. These data support the current TNM staging system, whereby renal pelvic and ureteral carcinomas are classified as one integral group of tumors.     

Factors Affecting the Survival of Patients Treated by Standard Nephroureterectomy for Transitional Cell Carcinoma of the Upper Urinary Tract

Purpose:In this study we tried to evaluate the predictive factors for survival in patients with upper urinary tract tumors. Materials and methods: From 1993 to 2003, 46 patients were treated by standard nephroureterectomy for upper urinary tract tumor, but only 24 patients (52%) who had regular follow-up were included in the study. Age, sex, presenting symptoms of the patients, tumor localization, tumor stage and grade were analyzed with respect to survival. Univariate and multivariate analyses were done using Kaplan–Meier method with log-rank test and Cox proportional hazards regression model, respectively. Results: The median of patient age was 61 years (34–74). Of the 24 patients, 9 (37.5%) were disease-free and alive at a mean time of 54 (26–97) months, 8 (33.3%) died of disease at a mean period of 23.4 months (2 because of bladder tumor, 2 had liver metastases, 1 had lung metastasis and 3 had lung and liver metastases) and 7 (29.2%) died disease-free at a mean period of 30.3 months. Metastases were detected in a mean period of 11.8 (6–24) months. Survival according to tumor stage Ta, T1-2, and invasive tumors were 87.5, 43.9, 15.7 months (p = 0.0001), respectively. Survival of the patients with low-grade tumors was significantly longer than those with high-grade tumors (77.3 and 31.4 months, respectively, p = 0.01). Patients with pelvis tumors when compared to ureter tumors (28.5 and 61.6 months, respectively, p = 0.038) and those presenting with flank pain when compared to those presenting with macroscopic hematuria and bladder cancer (17.7, 45.7, and 57.9 months, respectively, p = 0.046) had shorter survival rates. When multivariate analyses were done using Cox regression test, the only factor that affected survival was the stage of the tumor. Age and gender had no impact on survival. Conclusions: In univariate analysis, the stage, grade, localization of the tumor and presenting symptoms were found important predictors that affect the prognosis of the transitional carcinoma of the upper tract. However, tumor stage was the only independent predictor of survival in multivariate analysis. For high grade and high stage tumors, really effective adjuvant treatments along with aggressive surgery may be considered.     

腰部切口联合经尿道电切肾、输尿管全切术

目的探讨经尿道输尿管口电切在肾、输尿管全切术中的价值. 方法 2002年1月～2003年9月,我院采用腰部切口联合经尿道电切肾、输尿管全切术治疗28例肾盂、输尿管上段移行细胞癌.首先经尿道电切患侧输尿管口,然后经腰部切口切除肾及全长输尿管,术后留置导尿管7 d. 结果手术时间70～95 min,平均81 min.无尿漏、严重血尿及伤口感染等并发症.术后住院7～9 d,平均7.4 d.28例随访8～15个月,平均12个月,无肿瘤复发. 结论腰部切口联合经尿道电切肾、输尿管全切术创伤小、恢复快、安全.     

Case report: Microcystic Transitional Cell Carcinoma of the Urinary Bladder

We report a rare case of microcystic transitional cell carcinoma involving the urinary bladder, in a 38-year-old man, and we add our experience in the treatment of this neoplasm. The tumor was muscle invasive, and a radical cystectomy was performed. The patient received no postoperative chemotherapy or radiotherapy, and he has not signs of local recurrence or distal metastasis after 3 years of intense follow up. Even though the number of cases documented so far, is insufficient to draw safe conclusions regarding the optimal treatment of the microcystic variant of transitional cell carcinoma. Our case indicates that even in cases of microcystic transitional cell carcinoma with infiltrative nature, aggressive therapy is associated with good control of the disease locally and distally.